CONTINUING MEDICAL EDUCATION

Akreditasi PB IDI–2 SKP

The Effectiveness of Telerehabilitation for

Post Stroke Patients
Gabrielle Glenis,1 Regina Caecilia Setiawan,2 Tresia Fransiska Ulianna Tambunan1
1
Department of Physical Medicine and Rehabilitation, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta,
2
RSUD Gema Santi Nusa Penida, Klungkung, Bali, Indonesia.

ABSTRACT
Stroke rehabilitation is an essential component of post-stroke care and is more effective if started sooner. Stroke rehabilitation therapy aims
to improve motor function, psychological well-being, cognitively, emotionally, and in terms of social well-being. Telerehabilitation allows
communication between medical staff and patients and can be a suitable alternative to usual rehabilitation care in poststroke patients. This
method may have potential implications for patients, especially in remote or underserved areas. Future trials are needed on telerehabilitation’s
feasibility, efficacy, and cost-effectiveness in other low and middle-income countries where the stroke burden is burgeoning.

Keywords: Physical and rehabilitation medicine, stroke, telerehabilitation

ABSTRAK
Rehabilitasi stroke merupakan komponen penting dalam tatalaksana pasca-stroke dan lebih efektif untuk dimulai lebih awal. Tujuan terapi
rehabilitasi stroke adalah untuk meningkatkan fungsi motorik, kognitif, emosional, kesejahteraan psikologis dan sosial. Telerehabilitasi
memungkinkan komunikasi antara staf medis dan pasien dan dapat sebagai alternatif yang sesuai untuk perawatan rehabilitasi biasa pada
pasien pasca-stroke. Metode ini mungkin memiliki implikasi potensial bagi pasien, terutama di daerah terpencil atau kurang terlayani. Penelitian
masih diperlukan untuk kelayakan, kemanjuran, dan keefektifan biaya telerehabilitasi di negara berpenghasilan rendah dan menengah dengan
beban stroke meningkat. Gabrielle Glenis, Regina Caecilia Setiawan, Tresia Fransiska Ulianna Tambunan. Efektivitas Telerehabilitasi untuk
Pasien Pasca-Stroke

Kata kunci: Rehabilitasi, stroke, telerehabilitasi

Introduction of social well-being.7 Home-based telerehabilitation is defined

Stroke is one of the most common causes
of disability and mortality worldwide;1 70%
of people experience their first stroke over
65 years of age.2 Stroke rehabilitation is an
essential component of post-stroke care and
is more effective the sooner it begins.3
Clinical guidelines recommend that stroke
survivors with unmet rehabilitation goals have
timely access to specialized rehabilitation
services because physical function reaches
its peak around six months post-stroke and
begins to decline 1-year post-stroke.4-6 Stroke
rehabilitation therapy aims to improve the
patients’ motor function, psychological well-
being, cognitively, emotionally, and in terms
Alamat Korespondensi email: ggtrisnadi@gmail.com
Successful rehabilitation depends on stroke
severity, rehabilitation team skills, and the
cooperation of patients and their families.
However, many patients have reduced access
to care due to limited regional and logistical
resources. These patient groups could benefit
from a system that allows a health professional
to provide rehabilitation services from a
remote location.8
Telerehabilitation
Telerehabilitation was defined as “the delivery
of rehabilitation services that can eliminate the
main barrier cites by patients to participating
in supervised rehabilitation postdischarge”.9,10
as the use of telecommunication devices
(such as telephone, videophone, computer)
by a clinician to provide evaluation for
disabled persons living at home.3,11,12
These technologies allow communication
between medical staff and patients and the
transmission of imaging and other health
information data from one place to another.13
This is consistent with the holistic framework
that home-based poststroke telerehabilitation
should include support that spans an array of
medical, mental health, and other services.14
The aim is to provide a viable avenue to meet
the rehabilitation needs of stroke survivors in
resource-limited rural settings in developed
countries as well as low- and middle-income

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countries where stroke burden is rapidly
escalating.15,16
Over the past decade, some randomized
controlled trials (RCTs)20 investigated the
benefits of telerehabilitation in post-stroke
patients compared to usual rehabilitation
methods. The comparable improvement in
motor performance in the telerehabilitation
and standard care groups was evident on all
motor assessment scales. This adds to the
reliability of findings that telerehabilitation can
produce significant motor improvements.17
A systematic review by Sarfo, et al,17 showed
that telerehabilitation for motor and higher
cortical deficits and poststroke depression
appears to be as effective as in-person
therapies. The routine implementation of
telemedicine for post-stroke rehabilitation
could be essential for regions worldwide with
a lack of socioeconomic resources, including
under-resourced areas of high-income
countries, where neuro-rehabilitation experts
and facilities are virtually non-existent.18
Four studies16-19 aimed to improve stroke
survivors’ upper extremity function with
a virtual environmental-based motor
telerehabilitation intervention. Sensors
were placed either on the upper extremity
(arm/hand) or objects; sometimes, both
monitored patients’ exercises. The patients’
data were transmitted to a hospital-based
server. Two monitors, one for the real-time
video consultation and one for the virtual
environment-based tasks, were used in
these systems. Through the video consulting
system, the therapist could provide the
patient with different tasks and support the
patient when needed.19,20 One system used
the ISDN network to link the workstations.20
In a later publication, an Internet-based
broadband connection (ADSL) was used.20
In total, 63 stroke patients (intervention
groups ranging from 5–36 patients) were
included in the virtual environment-based
motor telerehabilitation studies. The length
of interventions varied from 4–6 weeks with
a one-hour session five days per week.19,20
Telemedicine can assist in improving motor
function from the onset of stroke, and
improved motor performance would further
translate into improved activities of daily
living.20
One telephone-based intervention developed
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a distant care program for stroke patients
discharged home to improve quality of
care. Telehealth nurses supported patients
(with family caregivers) according to their
individual needs, e.g., advised them how to
solve and cope with problems themselves.
The program consisted of telephone contact
and visits to patients’ homes. Another
telephone intervention aimed to develop and
maintain stroke survivors’ and their caregivers’
social problem-solving skills in home-based
settings.21
An Internet-based educational intervention
aimed to support stroke caregivers living in
rural communities. The participants were linked
to a customized educational care website
giving ‘tips of the month’ and educational
information. They also had the possibility
of participating in email consultations with
a specialist nurse or rehabilitation team. An
email discussion forum that offered caregivers
the opportunity to communicate with each
other and exchange personal experiences was
established.22
One study used a real-time video consulting
system in a community-based stroke
rehabilitation program. The system linked a
hospital and a community center for seniors.
A physiotherapist gave educational talks and
physical exercises and provided participants
with psychological support using the system.3
Video-based techniques may be a key
component of effective telerehabilitation.23
Three studies used 3D motion equipment and
software to generate virtual representations
of participants’ movements.24-26 Chen, et
al, combined video conferencing with
biofeedback and physiological data from
participants to overview intervention
parameters.27
In another systematic review, 13 RCTs
were analyzed. They showed that the
telerehabilitation system improved motor
function and a significant improvement for
activities of daily living, independence and
self-efficacy, patients satisfaction or quality of
life, and miscellaneous outcome (ROM, power,
and spasticity). They proposed significant
theoretical advantages for telerehabilitation
in addition to/instead of current stroke
rehabilitation therapies.28
A trial for one year of research followed by
3 to 24 months on poststroke participants
provided various views on telerehabilitation.
Each received 28 days of telerehabilitation
using a system delivered to their home. Each
day consisted of 1 structured hour focused
on individualized exercises and games, stroke
education, and an hour of free play. Each of
the 28 days of therapy consisted of 1 required
hour of activities selected by the therapist,
consisting of arm motor therapy and stroke
education. After treatment, there was one
optional hour of games chosen by the patient.
The system would not operate beyond the
permitted number of minutes. The result was
very please because it not only improved the
strength of the arm but also increased stroke
prevention and decreased depression in each
participant.29
The statement about stroke education in
telerehabilitation was supported by other
evidence from Palsbo SE,30 who said that
telerehabilitation interventions in stroke care
could also be used for educational purposes
and support caregivers of stroke survivors
living at home. Speech-language pathology
evaluation via video consulting instead of
face-to-face evaluation is feasible, although
no study included in the present review
explored this intervention. Speech-language
pathology therapies via telemedicine seem
to be a promising research area for stroke
patients with speech disorders.30
Other study31 included age 45 to 90 years
and experienced an ischemic or hemorrhagic
stroke within the previous 24 months,
doing stroke telerehabilitation (STeleR)
intervention consist of three components.
First, the three home televisits transpired
every 12 to 16 days and were completed
within five weeks of randomization. Second,
an in-home messaging device (IHMD) was
connected to a standard telephone line in
the participant’s home. and used the Patient
Health Questionnaire (PHQ-9) to screen
for depression at baseline (week 1–2) and
three months.4,10 Third, five telephone calls
were made from the teletherapist to the
participant. Calls occurred approximately
every 14 days, with the first occurring 7 to 10
days after Televisit 1. The other group is the
UC group, with participants that were not
contacted by study personnel. There were
no significant differences between the STeleR
and UC groups at baseline in the FONEFIM
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score. There was a better outcome in STeleR
than the UC group in LLFDI (Late-Life Function
and Disability Instrument) score. There was
bias in this study because of the patient’s poor
compliance.31
The survey on 129 participants showed that
more than half sample reported interest and
satisfaction in receiving assessments (58.4%),
training and exercise programs (64.0%), and
education (61.4%) via telerehabilitation.32
The devices that received the most
significant amount of interest across the
rehabilitation services were computers
(72.9% were ‘somewhat’ or ‘very’ interested),
television (68.7%), and landline telephone
(59.4%). Individuals younger than 65 had
a greater interest to receive training and
exercise programs (78.0% vs. 53.4%), as well
as education about stroke rehabilitation
(78.0% vs. 49.2%) through telerehabilitation,
compared to individuals 65 years of age and
older (p<0.05). The majority of respondents
agreed that telerehabilitation would make
them feel more independent (73.3%) and
more confident in managing their progress
(77.5%), as well as save them money in travel
expenses (72.7%). The majority also agreed
that they would like to receive rehabilitation in
their home environment (84.2%) and agreed
that telerehabilitation would make accessing
stroke care easier (82.8%).32,33
Telerehabilitation has several advantages
compared to usual rehabilitation, including
easier access, mentoring for disabled stroke
patients, and patients’ ability to self-record
their pain, mood, and activity.15 The primary
benefit of telemedicine in stroke management
is that areas with insufficient neurological
services can be supported by stroke experts
by telephone, via the Internet, or through real-
time video consulting, which may improve
the quality of stroke care. Other putative
advantages are cost-effectiveness (avoidance
of patient transport), reducing hospital
stay, improving stroke education (used in
secondary prevention), better efficiency in
implementing rehabilitation service, satisfying
patient choice/decision-making, improving
functional outcomes, and improving physical
health, and reducing caregiver strain.8,18,33-36
Many patients released from acute inpatient
rehabilitation have limited access to
outpatient rehabilitation, especially those
CDK-298/ vol. 48 no. 11 th. 2021
who live in rural areas. A wide variety of
telemedicine interventions in post-stroke
rehabilitation care were identified, and most
of them showed promising results.12 Using
telerehabilitation systems, it is possible to
provide rehabilitation services in patients’
homes or community-based settings. This
allows health professionals to monitor patients’
health status and to identify conditions that
need improvement before an adverse effect
occurs.12 A home-based telerehabilitation
system can assess patients for post-stroke
complications, educate patients about stroke,
and assess risk factor control; thus this system
can handle patients holistically.29
Unfortunately, several barriers limit the
spreading of telerehabilitation. These barriers
include administrative licensing, medico-
legal ambiguity, and financial sustainability.39
Another barrier, especially in low-income
countries (where telerehabilitation would be
most needed), is the lack of technological
infrastructure. A cross-sectional study (on 100
stroke survivors) in a Ghanaian outpatient
neurology clinic demonstrated that 80 to 93%
of patients had a positive attitude towards
telerehabilitation interventions. However, only
35% of them had smartphones.40 Installing
rehabilitation software on the computer,
laptop or smartphone was the most important
thing for the patient and the therapist to build
good teamwork among patients, therapist,
and patient’s caregiver. If one of them doesn’t
do well, this can have an adverse effect.41
Telerehabilitation has limited coverage; for
example, telerehabilitation doesn’t show
positive outcomes in patients with balance
problems because they need to be trained
assistance to help patients walk. Patients
should have a walking bar so patients can hold
on to the walking bar while they practice.28
It also raises challenges for rehabilitation
professionals.42 For example, a key issue
facing clinicians is conducting assessments
or providing interventions that are typical
“hands-on Such an issue speaks to a need to
modify current techniques and training, for
example, to bypass the need for a hands-on
approach and to perhaps instead engage the
assistance of a family member or a caregiver.43
However, there was also agreement that
telerehabilitation would result in fewer
in-person interactions with rehabilitation
professionals, that these interactions would be
missed, and that quality of care might be less
than face-to-face. Respondents were divided
on their opinion of whether they would not
want to discuss sensitive information over
technology.32
Overall, the studies included in this review
involved small populations,28,29,31,32 thus making
it difficult to reach any definite conclusions
about the effectiveness of telerehabilitation
interventions in post-stroke care. Patients
included in telerehabilitation interventions
generally suffered from mild impairment
after stroke and were living in home settings.
Whether telerehabilitation interventions are
suitable for patients with heavier impairments
is still to be investigated. Most studies showed
improvements in the outcome measures used
but failed to explain the clinical relevance
of these results. Finally, the present review
has at least one limitation: reports on
telerehabilitation are still comprehensive and
general. Further research is needed to focus
on telemedicine and stroke care.12
Telerehabilitation can be a suitable
alternative to usual rehabilitation care in
poststroke patients. This may have potential
implications for patients, especially in remote
or underserved areas. Further development
of telerehabilitation networks is essential to
overcome these barriers.42 Future trials on
telerehabilitation’s feasibility, efficacy, and cost-
effectiveness in other low- and middle-income
countries where stroke burden is burgeoning
are warranted. More extensive, well-powered,
longer-term studies are needed to establish
the routine utility of telerehabilitation for stroke
survivors globally.22 Moreover, the duration
of rehabilitation programs and frequency of
follow-up visits or contact with medical staff
differed from a study to another. So far, there
are no adequate data in the literature about
which model or telerehabilitation tool is
optimal for these patients, and future head-to-
head comparative studies are needed.9
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